Brenda Marshall, Ed.D, Psychiatric NP Associate Professor

Coordinator of the Doctor of Nursing Practice (DNP) Program

William Paterson University of New Jersey

Wayne, NJ 07470

DEVELOPED The Doctors of Nursing Practice Conference

St. Louis MO

September 19 2012

Objectives

Every Participant will be able to:

Describe the stages of change.

Identify methods to reduce the barriers and increase. the benefits of EBP by staff nurses.

Identify concepts of the Social Norms approach.

List three supports for seamless integration and methods to measure them.

FIRST STEPS Know where you want to go, and have a

person of vision supporting you, and a systems person capable of laying the groundwork.

Teamwork

Develop a framework for Progression of Evidence Based Practice (EBP)

Identify Model: Marker Model Standards development

Assess Existing Research Initiatives/Education (2

approved research projects)

Develop and Define the position of Director Evidence Based Practice (EBP)

Develop a Strategic plan that includes: EBP Council

Culture Change

Education and research support for staff nurses

PICO projects

Identify measurable Benchmarks

Identify a model/framework for EBP and a method of implementation Framework (2008-2009) Method (2009-2011)

Making the change work on the staff level

Be patient - True change takes time… Social norms are behaviors

that are accepted by the group as the expected behaviors.

Cultures support the norm.

Developing the culture of inquiry through using social norms must meet the nurses needs for acceptance.

Step One: Listen…

Take it to your nurses and respect their concerns

Identify the barriers and existing behaviors.

Support behaviors that move to goal.

Amplify the discrepancy between the anxiety born resistance , a fear of failure, and the possibility of personal success.

Find the leaders in the group and remove their barriers.

Does your social norm support Sacred Cows? FALLS ARE NOT A NURSING

CONCERN because patient falls happen infrequently and are not predictable!

BUT RESEARCH INDICATES that:

Some patients are at a higher risk for falling and can be identified through frequent assessment.

AND Falls can be prevented by using basic nursing strategies that address problems with elimination and ambulation.

SO Research demonstrates that nursing interventions directly impact patient outcomes and hospital reimbursement !

(Comried, et.al., 2004; Gillespie, et.al. 2000; Grol & Grimshaw, 1999; Hendrich, et.al, 1995; Heslin, et.al.,

1992; Morse, Black, Oberle & Donahue, 1989; Redus, et. al. 2002)

Amplify the discrepancy

Hospital wide implementation Identify groups for “BIG BANG”

Nursing Administration – Management

Joint Practice Clinicians – Management and Education

Patient Care Directors/Head nurses – Management of Pt Care

Care Managers/ Charge nurses – middle management, leaders and part of staff as well

Staff Nurses – bedside nursing

Choosing the Champions Care Managers – middle management/patient care/

union members

Care Manager identified as co-chair of the EBP /research committee

Using the Care Manager meeting, Care managers from each unit attended three, three-hour workshops

Education of Care Managers

Engagement of Care Managers in developing PICO questions

Establish a relationship between director of EBP and care managers

Providing the Workshops Methods:

Use of interactive clickers (TurningPoint technology)

Lecture and supported workshop components

Discussion – Q& A - Homework given

Lesson learned: identification of leaders, shared values, open resisters, early adopters and potential barriers, establishing rapport and trust between Director of EBP and Care Managers.

Three Half day workshops provided to ALL care managers. Introduction to IOWA model, vocabulary/terms of EBP, PI and

Research – what is a PICO question

Outcomes: Empowerment , increased knowledge and skills, Increased inter unit collaboration, Unit based PICO statements developed – champions identified, collaborative agreements developed between director of EBP and staff nurses.

Engage the medical librarian in all aspects of EPB!

Engaging management in facilitating adoption

Use existing documentation

Make sure there is someone to answer questions

Educate the Head Nurses

Recognize and reward behaviors that move towards the group goal.

Reducing the Barriers to Implementation

STEP TWO – develop self-efficacy The YET factor….

I can’t, we don’t, I won’t….

YET….

Provide ongoing support Research demonstrates that perception of ongoing

support significantly increases the engagement in behavioral change.

Recognize those nurses who engage and support their metamorphosis into change champions.

Creating a Social Norm for EBP Develop and Distribute bi monthly newsletter (6 issues)

Features explanation of EBP/research

Features nurses who get published, become certified, earn a higher degree, are recognized for an award.

Is distributed through e-mail and paper, posted on all units.

Wall of Publication Fame

Prominently displayed outside of the Nursing office, all nurses who get their EBP/research published get their article placed on display.

Results 1, 2 and 3 years after implementation positive changes were noticed…

One year after implementation Knowledge about EBP, IOWA Model of EBP, and

interest in the EBP council improved significantly.

Resistance to engaging in developing PICO questions and attending journal clubs increased.

Behavior change, leading to the care managers working with either Dr. Marshall or with other RN staff on EBP increased significantly

Changing knowledge to change attitudes

2009 2010

very limited 82% 5%

minimal 12% 0

practical 3% 53%

good 3% 21

excellent 0 21%

Changing attitudes to reduce resistance

2009 2010

58% resistant to EBP 0% resistant to EBP

36% uncertain to its value 11% uncertain to its value

4% begun to use in infrequently 50 use it on an infrequent basis

1% use it frequently 33% use it frequently

6% use it all the time 1% use it all the time

Changing Behaviors

2009 2010 2011

0

20

40

2009

2010

2011

2009 2010 2011

IndividualPICO project 2 17 37

Presented EBP council 3 15 10

presented poster at EHMC 2 7 17

Preented Nursing Grand Rounds 0 0 10

Unit has a PICO project 1% 76% 90%

More achievements: RESEARCH In September of 2009 there was 1 PICO project in development and 2 IRB

approved nursing research projects

By June of 2010 there were 18 PICO projects in place and 4 in development and 2 IRB projects.

By June 2011, there were 37 PICO projects and 11 IRB approved research projects.

Units prominently displayed their projects, and nurses were publishing in nursing magazines, journals and hospital publications.

Staff Nurses presented posters on their PICO statements and recognized at the hospital as well as at regional and national conferences for their research.

2011 Grand Rounds featured 10 ongoing

Original nursing research projects!

EDUCATION

Monthly journal clubs as part of the EBP council meeting, as well as unit based journal clubs.

Unit based online support.

Increased number of

nurses returning to school to pursue their Master’s degree and their Doctorate degrees.

Rubrics were developed and classes held on unit and in classrooms to simplify understanding the IRB approval process

Goals Objectives Baseline 9/2009

Outcomes 12/2010

Outcomes 6/2011

Increase staff EBP projects

75% units with identified project

Two projects in units

18 projects from all but 7 nursing units

37 PICO projects from all but 3 nursing units

Increase Journal club interest

Hold 5 journal clubs per year

1 journal club 5 journal 5 journal clubs

Increase interest in engaging in research

Present at EBP council before IRB submission

No PICO’s presented at EBP council

5 projects presented – all went to IRB

9 projects presented 6 went to IRB

EHMC poster presentations

Increase posters by staff nurses by 20% year

Regional and national 0 at medical center (MC)

7 posters presented at MC’s 18th Research Day

15 posters presented at MC Nurses Day poster gallery

RECAP Stages of Change and reducing barriers

Supports and Social Norms

To bring about this change we used the following theories:

Prochaska and DiClemente’s SOC = precontemplation, contemplation, preparation, action, maintenance and relapse.

Miller and Rollnick’s Motivational Interviewing Techniques.

Rosenstock’s Health Belief Model (HBM)

Utilize the existing forms where ever possible.

Provide face to face support, respond quickly to needs of staff, engage in empowering staff by education and research support, establish new liaisons to support staff research.

Develop the social norms approach that fits your hospital.

Be there for the nurses when they need you.

FEAR IS LIKE A FOG….

WHEN YOU WALK THROUGH IT…

NOTHING IS THERE.

-Michael Jordan

QUESTIONS? Contact Information Dr. Brenda Marshall, APN marshallb3@wpunj.edu

Tel: 973 720-3491

Fax: 973 616 5236

E-mail: marshallb3@wpunj.edu

References Titler, M.G., Kleiber, C., Steelman, V., Rakel, B., Budreau, G., Everett,

L.Q., Buckwalter, K.C., Tripp Reimer, T., & Goode, C. (2001). The Iowa Model of Evidence-Based Practice to Promote Quality Care. Critical Care Nursing Clinics of North America, 13(4):497-509.

http://www.uihealthcare.com/depts/nursing/rqom/evidencebasedpractice/iowarequest.html

Kimberly Jordan kimberly-jordan@uiowa.edu University of Iowa Hospitals and Clinics Nursing Research, Quality, and Outcomes Management

200 Hawkins Drive RM T100 GH Iowa City, IA 52242-1009

(319) 384-9098 Melnyk & Fineout-Overholt.(2005) Evidence-Based Practice in Nursing

and Health Care. Lippincott Williams & Wilkins. Philadelphia National Nursing Practice Network, NNPN, Application of Evidence

Based Practice, www.nnpnetwork.org/